By Dr Palla Trinadha Rao
Tribal people’s health faces several challenges. They inhabit the hilly terrain of Fifth Schedule areas that is difficult to access. Lack of awareness, functional health facilities, infrastructure, indifferent attitude of policy makers and health care providers, lack of codification and validation of tribal medicine, and lack of integration of traditional tribal health practitioners in the health care system are some of the key challenges in the health constituency.
This paper explores why tribal medicines and treatments for ill-health are not integrated into the health care system of the country? Is there any legal hurdle to validate the customary practices and beliefs of tribal peoples as well as traditional tribal medical practitioners, tribal medicines and treatments for at least a few common health ailments? This paper examines the policy and laws concerning the health in general, and more particularly local streams of tribal health care systems, medicines and treatments and integration of traditional tribal medical practitioners in the health care system.
According to Census 2011, the Scheduled Tribes constitute 8.6 percent of the total population of India. Infant Mortality Rate (IMR) in the Scheduled Tribes population is about 62 per 1000 live births and Under Five Mortality Rate (U5MR) is 96 per 1000 live births. Compared to rest of the population, IMR was higher by 27 percent and U5MR rate was higher by 61 percent. The 1-4 year mortality is 33.6 in Scheduled Tribes and 10.3 in the non-Scheduled Tribes (GoI 2014: 200).
The traditional medical practitioners rely on the indigenous knowledge systems, customary practices, beliefs and health seeking behavior of clients, provide medicine and treatments for health disorders. Their treatment has been based on empirical evidence often backed by the epistemology of recognized Indian systems of medicines (ISM). They use a variety of leaves, roots, barks, fruits, nuts, and seeds Etc., and treatment methods for treating various ailments. This knowledge is preserved and passed on to the next generation. The same raw material are the principle sources for ISM also. They are the doctors in the context of tribal regions, who have no degrees. It interesting to note that historically ‘doctors’ preceded ‘degrees’.
Belief Systems: Health Disorders
Tribals believe that hill goddesses, spirits are responsible for causing diseases and shamans could see and speak with them in trance and guide the patients to cure the sickness. If we agree that science has progressed, we need to acknowledge that whether traditional or modern, all needs to pass the scrutiny of science. Neither all of tradition or modern are all pure and scientific.
In the 21st century, traditional healers and their healing practices constitute a vital component in the Indian health-care system ( Kar N. 2008). Beliefs and help-seeking behaviors are highly correlated with each other and are greatly influenced by the culture. According to Hunter and Whitten, human beliefs are “thoughts that are based on the uncritical acceptance of the inherent truth or correctness of the cognitive categories of one’s culture.” (Hunter DE, Whitten P. 1976)
Hence, cultural beliefs highly influence health-related behaviors and are also reflected in a society’s health-care system. Cultural beliefs and practices affect nearly all aspects of mental illness, especially including assessment and diagnosis, illness behavior, and help-seeking and mutual expectations of interaction between patients and practitioners ( Weiss M (1997).
Tribal traditional medicine and practices face several challenges today including depletion of forest resources, displacement, and urbanization as well as the hegemony of other knowledge systems. “The essential thing is for the national health care system medical staff to take the right attitude to tribal medicine and the tribal priest. The most successful doctors have been those who have interested themselves in what we may call medical sociology, in such things as the tribal Pharmacopoeia, the tribal theory of the influence of dreams on health, tribal methods of diagnosis” (GoI 1961).
Although AYUSH (Ayurveda, Yoga and Naturopathy, Unani, Siddha, and Homoeopathy) systems are a part of the health care system to an extent, the tribal knowledge and healing practices, which are extremely diverse, remain largely unacknowledged and marginalized (Sama 2018). The origin of the medical systems – AYUSH – is from the traditional medicine through classical streams, while the ethno medicine, tribal medicine, folklore medicine are through the folk streams.(Singh 2018).However, these two streams overlap and have contributed to each other. But the fact remains that the Ayurvedic and Siddha texts acknowledge that a major source of knowledge about medicinal plants are from local communities, especially from forest people. So it is not as though that the local streams are disconnected from the classical streams. It appears that Ayurveda and Siddha texts are systematic records of tribal and other rural health practitioners.
The system of medicines which are considered to be Indian in origin or the systems of medicine, which have come to India from outside and got assimilated into Indian culture is known as ISM. There are six recognized systems of medicine in the Indian Systems of medicine category. They are Ayurveda, Siddha, Unani and Yoga, Naturopathy and Homoeopathy. “The literal meaning of Ayurveda is “The Science of Life;” the combination of two Sanskrit words “ayur” (life) and “veda” (science or knowledge) (Prasad 2002).
In a country like India where 80% of her masses live in rural areas, predominantly influenced by traditional practices wherever possible, in whatsoever manner or form available, and in the light of the grossly inadequate health care through modern medicine, positive rural biased policies of health care delivery is the only natural solution (Bijoy 1981).
Citing a study of Ms.Padma Srinivasan, a Senior Research Officer at the Indian Institute of Health Management Research in the World Health Forum, the High Court of Andhra Pradesh reiterated that during 19th and first half of the 20th Century, the traditional systems of medicine were gradually replaced by modern medicine, under the influence of the British Raj. During the period 1920-1940, Provincial Governments and popular leaders like Mahatma Gandhi, made various efforts to reverse this trend. But unfortunately, the country’s first National Healthcare Policy outlined in 1946 by Bhore Committee completely ignored the traditional practices. Subsequent Committees attempted to correct this error and in 1961, the Mudaliar Committee made strong recommendations for integrating modern medicine with the traditional medicine. But by that time, the dominance of modern medicine had become irreversible. (AP High Court 2017).
Policy and legal framework
“Health” is defined by the World Health Organization as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Therefore, the word “Health” cannot be looked through the narrow confines of the ailment and treatment alone but will also include the behaviour of health seekers and providers in the community in relation to physical, mental, emotional and other aspects.
Right to basic health care is part of the fundamental right to life. The States have an obligation to provide proper health services to all citizens. The UN Declaration on the Rights of Indigenous Peoples stipulates in Articles 24 and 25 that indigenous peoples must have equal access to social security schemes and health services, while these should take into account their specific conditions and traditional practices. “Where possible, governments should provide resources for such services to be designed and controlled by indigenous peoples themselves” (International Labour Standards Department 2009)
The Draft National Tribal Policy (2006) proposed a detailed, targeted strategy, which aims to address the specific problems faced by indigenous peoples in relation to health and medical care. This includes enhancing access to modern healthcare by developing new systems and institutions and a synthesis of Indian systems of medicine like Ayurveda and Siddha with tribal systems and modern medicine.
The Twelfth Five Year Plan (2012-17) had certain provisions with regard to Tribal Health. It recognized the need for evolving a new strategy that combines indigenous tribal medicine with other medical systems. It called for a systematic effort to document the traditional tribal knowledge of medicinal/herbal plants, standardize the information, and recognize it as an independent system of medicine. The plan even suggested involving traditional healers in providing health care by training them and entrusting them with the responsibility of treating people for remuneration.
The Expert Committee on Tribal Health, constituted in 2013 by the Ministry of Health and Family Welfare and Ministry of Tribal Affairs, GoI, on the principles of health care for the tribal people, underlined that a contentious but important issue is how to accommodate the indigenous medical system –the providers and therapies without sacrificing the scientific principles and methods of public health. In the name of scientific principles and safety, the baby need not be thrown out with the bath water. The traditional tribal medical system and the modern medicine, and public health will continue to coexist for at least a few generations. The objective is to facilitate a seamless integration where different systems of medicine coexist to provide the best possible care to the people from tribal communities.
The Pharma companies have been snooping around the tribal areas in the name of research on ethno medicine, extracting the traditional knowledge of tribals and exploiting them. “The grant of patents on non-original innovations (particularly those linked to traditional medicines), which are based on what is already a part of the traditional knowledge of the developing world have been causing a great concern to the developing world” ( R.A. Mashelkar, 2001)
An attempt to develop a synergy between the Kanitribes who have traditional knowledge in relation to a plant Trichopus zeylanicus (Arogyapacha ) which claimed to be useful to bolster the immune system, and the Scientists at the Tropical Botanic Garden and Research Institute (TBGRI) in Kerala to develop the medicine and marketing it on an equity share basis, has ended without setting any better example, due to a number of reasons including protests from Muttu Kanis (the medicine men) against the transfer of this knowledge without the permission of Kanis tribes and the loss of right to access Arogyapacha in the forest in view of restrictions imposed by the Forest Department etc.
On the other hand, in despite of a fact that the Drugs and Magic Remedies Objectionable Advertisements Act-1954 disallows the misleading advertisement of certain drugs for treatment of certain diseases and disorders, markets have been flooded with several products. Ayurvedic products, especially cosmetics are being advertised in the electronic and print media for propagation of these products. The Pharma Industry in the name of traditional medicine, inducing the public to resort to self-medication by reason of its elated advertisements.
It is also a fact that it’s inadequate to show the pharma industry as the only villain in commodification. Commodification is the essence of the market for capitalism pervading all human activity, whether modern or traditional. Commodification that geographically centered around growth centres have progressed rapidly into the hinterland and marched into the forest heartland too in varying degrees.
The knowledge and skills of traditional medicines should be protected through community ownership. The ownership and intellectual property rights of tribal community over their own medicines and practices should be ensured. Building their capabilities to care for their health is the long-term solution, far superior to a perpetual dependence. In other words, instead of ‘giving’ health care, the policy should be to build ‘capacity to care for health’. (GoI 2014). Thus the Government should take up measures to protect and promote the traditional medicines of indigenous peoples and ensures the ownership of community over their own herbal treatment practices.
The National Health Policy (NHP) endorsed by the Parliament of India in 2017 also advocates for research and validation of tribal medicines (GoI 2017). The Constitution of India recognizes customs and customary practices. The term ‘law’ in Article 13 includes ‘customs’ and ‘usages’ having the force of law but not infringing any of the fundamental rights conferred by part III of the Constitution. Therefore, the customary practices of tribal medicine and treatment of traditional tribal medical practitioners cannot be prevented unless they violate the fundamental rights of a citizen. Further, the PESA Act 1996 provides that “(N)otwithstanding anything contained under Part IX of the Constitution, every Gram Sabha shall be competent to safeguard and preserve the traditions and customs of the people, their cultural identity, community resources” (Section 4d) in the Scheduled Areas.
Constitutional Scheme to protect the Tribes Chapter VI, Part X of the Constitution deals with “Scheduled Tribes and Tribal Areas”. Article 244 provides that the provision of the Fifth Schedule shall apply to the administration and control of the Scheduled Areas.
Customary laws and traditional institutions of governance constitute the basis of biodiversity conservation, sustainable use and preservation, and development of Indigenous Knowledge. Territorial rights and self-determination are fundamental to this. National and international laws and policies, along with the modern development paradigm, criminalize these traditions by not recognizing and providing effective legal status to them (Bijoy 2007).
Across the world, traditional medicine (TM) serves as complementary to modern health care delivery. In some countries, traditional medicine or non-conventional medicine may be termed complementary medicine (CM) and a global strategy to foster its appropriate integration, regulation and supervision will be useful to countries wishing to develop a proactive policy towards this important – and often vibrant and expanding – part of health care (WHO 2013).
However, the Indian Systems of Medicines have increasingly become unaffordable even as its accessibility and availability have increased. The cost of these medicines surpasses the costs of modern medicine (Allopathy). It is no longer affordable to the poor.
There is a need to protect the community resource rights. This alone would protect the people’s right to produce knowledge from the natural resources. It also serves to preserve, promote, and evolve knowledge from natural resources around. This would lead to community initiative to take measures to protect and prevent the decline of resource base of tribal communities.
The 2006 law on Scheduled Tribes and Other Traditional Forest Dwellers (Recognition of Forest Rights) Act, 2006 recognizes community rights as well as individual forest rights, including the rights to hold, live and cultivate on the forest land and ownership over minor forest produce. “For the first time, the ‘right of access to bio-diversity and community right to intellectual property and traditional knowledge related to forest biodiversity and cultural diversity’ features in the law ‘Scheduled Tribes and Other Traditional Forest Dwellers (Recognition of Forest Rights) Act, 2006’ in 3(k) under ‘Forest Rights’. (Bijoy 2007)
Indigenous and local communities, who either grow “biological resources”, or have a traditional knowledge of these resources, are the beneficiaries under the Biodiversity Act 2002. In return for their parting with this traditional knowledge, certain benefits accrue to them as Fair and Equitable Benefit Sharing (FEBS), and this is what FEBS is actually all about(Uttarakhand High Court 2018).
According to Section 3(b) (i) of the Drugs and Cosmetics Act 1940, the expression “drug‟ covers broadly, as a medicine or within its ambit any substance which is used for or in the treatment, prevention and mitigation of a disease or a disorder. Under the Panchayat (Extension to Scheduled Areas) Act (PESA) of 1996 for the Fifth Schedule area, for the first time, there is a clear direction that the Legislature of a State shall not make any law that is not in consonance with the customary law, social and religious practices, and traditional management practices of community resources (Clause 4a). Therefore, the Drugs and Cosmetics Act 1940 and Rules made should be modified in conformity with the provisions of PESA Act 1996 by providing legal space including the tribal medicine for treatment, prevention and mitigation of a disease or a disorder.
The AP High Court recently permitted a Petitioner (B.Anandiah (WP (PIL) Nos.105, 106 & 10806 OF 2021) to administer his traditional/country medicine for Corona Virus. The main contention of the Petitioner is that the herbal preparation made by him, shall come under the category of ‘patent or proprietary medicine’ as defined under section 3(h) of the Drugs and Cosmetics Act, 1940, and he is a practicing Ayurvedic doctor for many years and even no license is required for the drug he was making under provisions of Section 33 EEC of Drugs and Cosmetics Act.
The policies and law permit the traditional tribal medical practitioners to follow the customary practices in treating the health disease or disorders. However, the Central and State Governments have failed to give proper attention to the tribal medicine, which is affordable and accessible to tribals in Fifth Scheduled Areas. There is a need to document the tribal medicine practices and investigate them for their efficacy for various ailments and analyze scientifically in order to establish its due position of eminence in the health care system and structure. Further there is a need to exercise control over collection of herbal plants by pharmaceutical companies, who often resort to unsustainable extraction of plant and other resources. The PESA Gram Sabha shall be strengthened to protect the biodiversity as well as to maintain community forest resources and cultural heritage. So it’s not a matter of tribal, traditional or modern medicine that matters. What finally matters is whether I can lead a healthy life. The health care system plays only a small role though critical role at times.
AP High Court 2017. M/S. Manthena Satyanarana Raju vs The Union Of India, 7 February.
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